Uniform state system needed for investigating deaths, critics say

County coroners don't have expertise that medical examiners do, they claim

RUTH TEICHROE, SEATTLE POST-INTELLIGENCER

By RUTH TEICHROEB, SEATTLE POST-INTELLIGENCER REPORTER

Published 9:00 pm, Wednesday, October 30, 2002

Dr. Richard Harruff, King County's chief medical examiner, with X-rays of a young child who died. Under state law, only the six largest counties in the state, out of 39, can hire medical examiners; the rest must use coroners.
Photo: Scott Eklund/Seattle Post-Intelligencer

For a filing fee of about $300, anyone from a plumber to a police officer can run for coroner in almost half of Washington's 39 counties.

By law, an elected prosecutor does coroner duty on the side in most of the rest. Only the six largest counties put medical examiners who are forensic pathologists in charge.

That piecemeal approach is one of the biggest barriers to improving child death investigations, say experts who advocate a statewide medical examiner system.

"In general, the coroner counties don't investigate," said Dr. Cliff Nelson, a deputy state medical examiner in Portland, who formerly worked in Clark County. The most important call a coroner makes is what and how to investigate. Many coroners can do a good job on "obvious cases" and administrative duties, Nelson said. But they can't make up for not having the training or budgets to do the complex investigations crucial to detecting suspicious child deaths.

To make matters worse, the state doesn't monitor how counties investigate deaths.

"What's really needed is state oversight of the entire death investigation system," said Dr. Richard Harruff, King County's chief medical examiner, who trains coroners in infant death investigations. "There are irregularities throughout the system because of the way the law is written."

State law says that only counties with a population of 250,000 or more can hire medical examiners, while the rest must use coroners. Counties with less than 40,000 people must elect a prosecutor/coroner.

Coroners say they're an effective, less costly option.

Judy Arnold, Thurston County's 22-year coroner, said rural counties can't afford to pay a forensic pathologist, at more than double her salary.

"They're experts on autopsies but aren't necessarily good administrators," she said.

Most new coroners take advantage of a 40-hour orientation program offered by the Washington Association of Coroners and Medical Examiners and take part in annual training to improve their skills.

Arnold argues that elected coroners are more independent than county-appointed medical examiners who have to worry about being fired.

When coroners decide an autopsy is needed, they use local pathologists for autopsies, contract with nearby medical examiners or hire one of the few forensic pathologists who are available on a fee-for-service basis.

"You get what you pay for," said Dr. Donald Reay, King County's retired chief medical examiner.

A regular pathologist is more likely to miss signs of child abuse and neglect, or be reluctant to make a tough call, Reay said. Cost has determined whether extra tests are done, including high-quality full-body X-rays. Experts say many X-rays on infants are so poorly done they miss broken bones and other signs of abuse.

But counties can no longer blame cost for the quality of child death investigations. As of a year ago, the state pays the full fee for autopsies of children under 3 who died unexpectedly if specific standards are met.

Ideally, every young child who dies accidentally should also be autopsied to help rule out foul play, said Reay.

Autopsies were not done on 25 percent of 267 accidental deaths of children 5 and under across this state in the last five years, a Post-Intelligencer analysis found. That included two infants who drowned in bathtubs.

Across the country, 17 other states rely on mixed coroner-medical examiner systems of death investigation like Washington, while 21 states, plus the District of Columbia, put medical examiners in charge and another 11 use coroners. Oregon has a statewide medical examiner system, with deputy medical examiners in each of its 36 counties.

"We've taken the politics out of death investigations because we are all state employees," Nelson said.

New Mexico, with a population of 1.7 million, has had a statewide medical examiner for decades. When anyone dies unexpectedly, the body is flown to the medical examiner's office in Albuquerque for an autopsy. On-call death investigators around the state respond to the scene, take photos and do interviews.

Child deaths in that state receive extra scrutiny, including consultations with pediatric specialists, state social services officials, plus monthly reviews by a state child-fatality board.

Missouri, a state with about the same population as Washington -- about 5.9 million -- and a coroner-medical examiner system, has had a county-based child fatality review system for a decade.

By law, the fatality review panels are notified within 24 hours of a child's death and meet as soon as possible. The panel must submit its findings to the state before a death certificate is signed off. Autopsies are done by "certified child pathologists" approved by the State Technical Assistance Team, which oversees child-fatality reviews.

Experts say increased scrutiny is partly why Missouri's infant homicide rate is three times that of Washington -- a sign that the death-investigation system is working.

This state's review process is just starting to gather enough data to generate information about how to better protect children, including the finding that DSHS had contact with one-third of families where a child died of abuse or neglect. But critics say the teams lack the legal clout to influence death investigations.

Even the minimal oversight provided by the child death reviews is in jeopardy because of the state's budget problems. For the last two years, the $500,000 annual funding for the child death reviews has come close to being cut by the governor.